Evaluating anti-bullying training in surgery: surgeons’ perceptions from Australia and Aotearoa New Zealand

Paul Gretton-Watson; Jodi Oakman; Sandra G. Leggat

doi:10.1071/AH24104

RESEARCH ARTICLE (Open Access)

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Evaluating anti-bullying training in surgery: surgeons’ perceptions from Australia and Aotearoa New Zealand

Paul Gretton-Watson ^A ^* , Jodi Oakman ^B and Sandra G. Leggat ^A

+ Author Affiliations

- Author Affiliations

^A School of Psychology and Public Health, La Trobe University, Bundoora, Vic 3086, Australia.

^B Safety and Health, Centre for Ergonomics and Human Factors, School of Psychology and Public Health, La Trobe University, Bundoora, Vic 3086, Australia.

^* Correspondence to: 82041187@students.latrobe.edu.au

Australian Health Review 48(5) 576-584 https://doi.org/10.1071/AH24104

Submitted: 5 August 2023 Accepted: 2 August 2024 Published: 26 August 2024

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Objective

To evaluate how surgeons in Australia and Aotearoa New Zealand perceive the effectiveness of the Operating with Respect (OWR) face-to-face training program in reducing workplace bullying.

Methods

A cross-sectional survey examined the perceived effectiveness of the Royal College of Surgeons’ (RACS) face-to-face OWR training and complementary interventions in reducing workplace bullying in surgical settings. The sample included supervisory surgeons, RACS committee members, and targeted educators. The survey instrument had 35 questions, including five related to the research question. In December 2020, the survey was distributed by RACS to all surgeons who undertook OWR training between April 2017 and December 2019. Likert scales and coded free text responses were used to explore the effectiveness of face-to-face OWR training and other interventions included in the 2015 RACS Action Plan.

Results

Of the 756 surveys sent, 252 were received. The face-to-face OWR training program was rated as moderately effective. RACS’s overarching approach to anti-bullying was almost equally important, highlighting the need to consider a broader ecosystem of reform.

Conclusions

This study finds the RACS full-day anti-bullying training moderately effective in reducing bullying in surgical workplaces. However, enhancing its impact requires a sustained, multi-faceted strategy, including broader policy reforms, accountability measures, and cultural changes, to foster a long-term respectful environment in surgical settings.

Keywords: anti-bullying, bullying, disrespectful behaviour, organisational culture, surgeons, surgery, surgical workplaces, training, training programs, workplace bullying, workplace culture.

Introduction

Bullying behaviour remains a serious issue in today’s surgical workplaces¹^–⁶ with a landmark study finding that 54% of trainee surgeons and 45% of fellows less than 10 years post-fellowship report being subjected to bullying.³ While a significant body of literature has examined the prevalence and impact of bullying in surgical settings for different professionals and trainees,⁵^,⁷^–¹⁴ there is a lack of consensus on which interventions are most effective in addressing workplace bullying in surgery.⁶^,¹⁵^–¹⁸ Research on surgeons’ perspectives, particularly regarding the effectiveness of anti-bullying training, is notably limited,¹⁹ despite the significant influence of surgeons in these settings. Most research on this topic has originated in North America and Europe,¹^,²⁰^–²³ with limited comparable research in Australia or Aotearoa New Zealand.²⁴^,²⁵

The purpose of this study is to evaluate the perspectives of surgeons in Australia and Aotearoa New Zealand on the effectiveness of the Operating with Respect (OWR) program in reducing workplace bullying, a program developed by the Royal Australasian College of Surgeons (RACS) in 2015.²⁶ The focus is on its mandatory full-day training course, structured to provide advanced training in recognising, managing, and preventing discrimination, bullying, and sexual harassment. Its core objective is to cultivate a safe, respectful workplace culture that enriches trainee learning and, consequently, enhances the quality of surgical care.²⁶ In addition to the OWR training, the perceived effectiveness of additional interventions initiated by RACS and surgical employers to combat workplace bullying are analysed, these include: an OWR e-learning module (July 2016–present), the OWR Speak-Up App (launched May 2019), reinforcement publications and promotional campaigns (2015 to December 2020), RACS’s revised complaints management process, and employer-driven strategies to curb bullying and harassment. Finally, there is an exploration of the key factors perceived to be necessary to further reduce bullying.

Background

In 2015, RACS established an Expert Advisory Group (EAG) of independent experts to discover the pervasiveness of discrimination, bullying, and sexual harassment in surgery across Australia and Aotearoa New Zealand.³ The prevalence survey identified alarmingly high levels of these behaviours and experiences across a range of surgical cohorts. The RACS definition of bullying is as follows: ‘Bullying is unreasonable behaviour that creates a risk to health and safety. It is behaviour that is repeated over time or occurs as part of a pattern of behaviour. ‘Unreasonable behaviour’ is behaviour that a reasonable person, having regard to all the circumstances, would expect to victimise, humiliate, undermine or threaten the person to whom the behaviour is directed.’ (p. 19)¹⁶

Following receipt of the EAG report, RACS developed an initial action plan: Building Respect, Improving Patient Safety (BRIPS)²⁶ based on recommendations from the EAG report.²⁷

While the overarching BRIPS project was initiated in 2015, the OWR education component was launched as an online module in 2016. Subsequently, the face-to-face course, the subject of this paper, was piloted between 2016 and early 2017 before its official launch in 2018. Based on a recommendation in the 2015 Crebbin study,³ the OWR training was mandatory for the RACS Surgical Education and Training (SET) Supervisors, International Medical Graduate (IMG) Supervisors, and RACS Senior Board and Committee Members. This study focuses on participants who undertook the training between April 2017 and December 2019.

Methods

An online cross-sectional survey assessed the perceived effectiveness of RACS’s OWR training-related interventions since 2015. In December 2020, the survey was distributed by RACS to all surgeons who undertook OWR training between April 2017 and December 2019 (n = 756).

The survey instrument comprised 35 questions including a mix of standardised items and focused inquiries, centred on five questions specifically designed to assess the effectiveness of the OWR anti-bullying training and other interventions deployed by RACS as part of the 2015 RACS Action Plan.²⁶ These core questions, derived from relevant research themes, were thoroughly reviewed for structure and content by expert co-authors. See Appendix 1 for a summary of the key findings in the EAG report and RACS Action Plan.³^,²⁶

A non-mandatory, free-text question was analysed inductively using NVivo software to aid thematic analysis and sense-making.²⁸^–³¹ Ethical approval for the study was granted by the Science, Health and Engineering College, Human Ethics Sub-Committee at La Trobe University in August 2018 (HEC 18308).

Results

Of the 756 who completed the OWR face-to-face full-day training, 262 (34.65%) responded to the survey. Table 1 and Fig. 1 detail the effectiveness of various interventions. The OWR face-to-face training course was rated 3.02 (s.d. = 1.15) for perceived effectiveness, compared to the OWR Speak-up App’s lower effectiveness rating of 2.03 (s.d. = 1.06). Respondents expressed relatively strong support for RACS’s overarching OWR strategy and anti-bullying stance, evident in its higher mean score of 3.01 (s.d. = 1.12), highlighting the need for a multi-pronged approach that combines digital and face-to-face interventions as part of a comprehensive framework of measures to address workplace bullying more effectively.

Fig. 1.

Perceived effectiveness of intervention strategies from most to least effective (n = 262).

Table 1.Perceived effectiveness of interventions to improve workplace bullying.

Item	Overall (n = 262)
1. OWR eLearning	Mean (s.d.) 2.53 (1.08)^A
2. OWR face-to-face, Training Course (full day)	Mean (s.d.) 3.02 (1.15)
3. OWR Speak-up App	Mean (s.d.) 2.03 (1.06)
4. Other reinforcement activities including publications and promotional efforts	Mean (s.d.) 2.49 (1.03)
5. RACS’s revised complaints management process	Mean (s.d.) 2.18 (1.15)
6. Strategies to reduce bullying within your employing organisation(s)	Mean (s.d.) 2.39 (1.12)
7. RACS’s overall OWR strategy and anti-bullying stand	Mean (s.d.) 3.01 (1.12)

^A Likert scale: 1 not effective at all, 2 slightly effective, 3 moderately effective, 4 very effective, 5 extremely effective.

Table 2 explores respondents’ agreement with a range of statements relating to RACS and employing organisations’ efforts to address bullying and build respectful cultures.

Table 2.Respondents’ agreement with statements related to RACS and employing organisations’ efforts to address bullying and build positive culture.

Item	Overall (n = 262)
1. RACS has been instrumental at reducing bullying or disrespectful behaviour in surgical settings	Mean (s.d.) 4.89 (1.63)^A
2. RACS should have done more to embed positive workplace behaviour following the training	Mean (s.d.) 4.42 (1.50)
3 RACS has focused too much on the OWR strategy at the expense of other priorities important to surgeons	Mean (s.d.) 3.68 (1.69)
4. The RACS OWR initiatives would not be successful without the response to bullying, or disrespectful behaviour, of my organisation(s)	Mean (s.d.) 4.66 (1.67)
5. My employing organisation(s) have been more effective at reducing workplace bullying than RACS	Mean (s.d.) 3.25 (1.60)
6. Managing complaints related to bullying remains a problem requiring improvement for RACS	Mean (s.d.) 4.89 (1.66)
7. Managing complaints related to bullying remains a problem requiring improvement for my employing organisation(s)	Mean (s.d.) 1.34 (1.50)
8. RACS’ complaints processes for dealing with workplace behaviour have improved greatly since the OWR strategy was implemented	Mean (s.d.) 4.46 (1.57)
9. It is only the employing organisation that should be responsible for managing complaints about workplace behaviour involving surgeons	Mean (s.d.) 2.74 (1.67)
10. It is only RACS that should be responsible for managing complaints about workplace behaviour involving surgeons	Mean (s.d.) 2.27 (1.35)
11. Today, surgeons who are ‘known’ bullies are being more effectively managed	Mean (s.d.) 3.74 (1.59)
12. Some surgeons who are ‘known’ bullies seem to keep getting away with it	Mean (s.d.) 5.10 (1.68)

^A Likert scale: 1, strongly disagree; 2, disagree; 3, somewhat disagree; 4, neither agree nor disagree; 5, somewhat agree; 6, agree; 7, strongly agree.

Most respondents viewed RACS positively in reducing bullying and disrespectful behaviour but were neutral on whether more should be done post-training. The respondents had mixed views on whether RACS has excessively focused on the OWR strategy at the expense of other priorities important to surgeons. The success of RACS’s OWR initiatives was considered dependent on employing organisations being similarly aligned with implementing anti-bullying policies and interventions.

Respondents strongly agreed that bullying complaints remain a problem requiring improvement for employing organisations. The respondents disagreed that either the employing organisation or RACS alone should manage complaints, viewing it as a shared responsibility. Regarding known ‘bullies’, there was mild agreement they continue to go unpunished, with a wide variety of responses to this statement.

Table 3 explores the free text question which asked participants to suggest the one thing what would make the biggest difference to further reducing bullying in surgical workplaces. This question received 129 responses. Data were organised into semantic themes and coded into six master themes and 17 subthemes using NVivo software. The master themes are arranged in descending order based on the frequency of occurrence in the coded data.

Table 3.Respondents’ free text responses: What’s the one thing that would make the biggest difference to further reduce bullying in surgical workplaces?

Master theme	Subtheme	Representative comment
More training and education	More anti-bullying/respect training	‘Increased education and support for reporting of bullying and then management.’
		‘Education for all members of the surgical team, not just the surgeon.’
		‘Good induction programmes with clear instructions from the start of any job.’
		‘Target intervention at known offenders.’
		‘Nobody can be told what to think but people can be encouraged to start to think.’
	Stay the course – broaden rollout of OWR and RACS reforms	‘Persevere with the programme.’
		‘Mandatory OWR face-to-face course for all RACS members.’
		‘Effective implementation of what we have available.’
		‘The cake is in the oven, maintain the course.’
		‘Ongoing training and workshops like OWR.’
Accountability, visibility, and consequences	Accountability and zero tolerance	‘Serial bullies are protected for financial reasons.’
	Accountability and zero tolerance	‘Senior administration … one strike and they are sacked, surgeons … one strike and they are fine.’
	Visibility of behaviours	‘CCTV!’
	Visibility of behaviours	‘Education to call out bullying behaviour and consequences made visible.’
	Consequences	‘More significant consequences for repeat offenders.’
	Consequences	‘The College acting against senior surgeons who are known bullies, not just juniors.’
Culture building	Actively build a positive culture	‘A change in the culture of the managers in the public hospitals.’
		‘Continued change of the culture that surgeons particularly are entitled to behave in this manner.’
		‘Building a culture, this does not come from one or two courses.’
	Role of leadership	‘Cultural change within workplace. Can be led by surgeons and this is where RACS can play a role.’
		‘The onus of change to lie with surgeons, not trainees.’
		‘The personal ethics, maturity and responsibility of individual surgeons need to improve.’
		‘Promote training supervisors/dept heads who have positive leadership.’
	Diversity in surgical teams	‘More diversity in surgical culture and celebration of the value that brings.’
	Diversity in surgical teams	‘More women in surgery.’
	Manage expectations actively	‘The junior staff in particular should recognise the difference between work delegation and bullying.’
		‘A clear understanding of mutual expectations and skill sets within the team.’
		‘Team members seeing the bigger picture, busy ward, on call, full clinic, tough ops, all contribute.’
		‘Willingness and openness to discussion about differing perceptions and expectations.’
	Respect	‘Just basic human respect for others.’
		‘Respect each other for who we are.’
		‘Do unto others as you would have them do unto you.’
Complaint processes and empowerment	Improve complaints processes	‘Better complaints system with teeth.’
		‘An anti-bullying lead within the hospital, ideally a senior surgeon who can be approached.’
		‘Take complaints seriously, formal investigations, if substantiated, clear and real consequences.’
		‘If the lawyers of the unions stopped supporting bullies when the organisation instituted action.’
		‘Have an independent anonymised “Bullying reporting department“ with interventional powers.’
		‘Adequate resources to investigate in a timely manner.’
	Empowerment of ‘victims’	‘Make it culturally acceptable to the point that victims are empowered to speak out.’
		‘Further empower/encourage the junior staff to respond to bullies and to report them.’
		‘Reduce perceived risks to those wishing to call out bad behaviour.’
		‘Empowering nurses in private hospital theatres.’
Broader health system reform	Expanded role of employing hospital and executive	‘Hospital managers who are not afraid of their surgical workforce.’
		‘Getting buy-in and role modelling from hospital management.’
		‘Most of the bullying actually occurs from management in public hospitals.’
		‘Private hospitals taking a stand with surgeons who are known to consistently bully.’
	Expanded reform agenda	‘Government ministry for health and public hospital executives need to comply with OWR.’
		‘We’re cleaning up our act, other specialties haven’t even owned their own bullying behaviour.’
		‘Collaboration between the workplace leadership (surgical HOU, program directors etc.).’
		‘Teach nurses and unionised techs not to bully other staff. They are untouchable.’
		‘Explicit cooperation and information sharing between workplace and RACS.’
	Reduce stressors	‘Start fixing inept systems which cause frustration (EMR/Waste/Theatre access/Identity politics).’
	Reduce stressors	‘Reduction of stress associated with limited resources leading to patients’ dissatisfaction.’
Screening out bullies or moving them on	Generational change	‘Generational change, character competent leadership.’
		‘The next generation of surgeons – better in UK as older generation who would not change retire.’
		‘The retirement of older surgeons and the offending bullies!’
		‘Retirement. Sadly, older generations don’t see the issue, younger generations are waiting for.’
	Recruitment and screening	‘Review selection process of registrar training. Mandate OWR for CPD.’
		‘Address it during junior years/training years.’
		‘Trainees should be screened for their behavioural patterns, to weed out future bullies.’
		‘Selecting trainees with compassionate nature and nurturing them.’
		‘Ensure known bullies do not end up on RACS committees/leadership roles.’

The need for a broader rollout of anti-bullying training and education was the most frequently cited solution. Respondents emphasised strengthening initiatives and expanding them to include a wider range of healthcare professionals.

Additionally, respondents highlighted the critical role of accountability, visibility, and consequences in combatting workplace bullying. They advocated for clear accountability measures, zero-tolerance policies, and visible consequences for repeat aggressors, underlining the significance of leadership in actively fostering a positive culture within surgical teams. Respondents suggested a need for promoting diversity, particularly in increasing gender diversity within surgery, as a pivotal aspect in cultivating an inclusive, supportive culture and workplace environment.

Furthermore, improving complaint processes and empowering individuals who experience bullying were identified as essential strategies to encourage reporting of bullying behaviour. Participants stressed the need to streamline complaint procedures and provide robust support mechanisms for those who come forward with reports of bullying. While these themes represented the most frequently reported aspects, less frequently noted themes such as broader health system reform and the need for screening out bullies or moving them on, also underscored the importance of a comprehensive and nuanced approach to addressing workplace bullying.

Discussion

Analysis of the OWR program’s perceived effectiveness underscores the complexity of addressing workplace bullying. The moderate effectiveness of the face-to-face training contrasts with the lower effectiveness score for the OWR Speak-up App indicating that digital tools alone may not be sufficient. This disparity highlights the need for a multi-faceted strategy combining traditional training with robust support and accountability measures. While there is general support for RACS’s anti-bullying strategy, the mixed feedback post-training calls for continuous refinement of the approach to meet the evolving needs of surgical environments.

This research examined the perceptions of surgeons after completing the full-day mandatory face-to-face OWR training (between April 2017 and December 2019), indicating the potential for enduring behavioural change, consistent with findings from prior studies.³²^,³³ In recent years, RACS and employing organisations across Australia and Aotearoa New Zealand have deployed a range of strategies to reduce bullying and improve surgical culture.³⁴^–³⁶ Consistent with recent literature,¹⁷^,³²^,³⁷^–⁴¹ this sustained, long-term commitment to anti-bullying measures is necessary to achieve durable improvements in workplace culture.

The literature on the efficacy of anti-bullying interventions reveals mixed results.¹⁷^,³⁷^,⁴² Some researchers have found that training alone can reduce bullying behaviour and improve organisational culture³²^,³³^,⁴³ while others find minimal lasting behavioural change from anti-bullying training.⁴⁴ However, there is greater consensus in the literature that anti-bullying training is more effective when integrated with complementary interventions.³²^,³⁹^,⁴⁵ This may include well-designed anti-bullying policies, increased accountability and consequences for bullying behaviour, improved complaints processes, empowerment of those experiencing bullying to act, the use of state-of-the-art, trusted digital tools and other anti-bullying reinforcement or embedment strategies.¹⁷^,³⁴^,³⁷^,³⁹ The most recent literature suggests greater differentiation and targeted interventions for those experiencing bullying, witnesses, and aggressors rather than the more typical generic and homogenous anti-bullying training for all.⁴⁶

The study findings suggest that surgeons consider cultural change in surgery as a dual responsibility between RACS and employing organisations³⁴^,⁴⁰^,⁴⁷^–⁵⁰ who need to collaborate to ensure longer term reforms. While RACS develops the professional standards for surgeons, participants recognised that employers are responsible for the management of disrespectful behaviour and complaint and remediation pathways to reduce workplace bullying.

Analysis of this study’s data necessitates a deeper examination of internal inconsistencies in our data, participant motivations, and organisational dynamics. Conflicting perspectives among participants underscore the complexity of addressing workplace bullying.⁵¹^–⁵⁵ Insights into the top-down nature of bullying behaviour, with some attributing it to management,⁵⁶^–⁵⁸ highlight the role of organisational factors’ in perpetuating or mitigating bullying. The contradictory calls for action, such as encouraging trainees to both ‘toughen up’ and ‘report more’, underscore the tension between individual resilience and systemic support mechanisms within surgical workplaces, a tension noted in the literature³²^,⁵⁶^,⁵⁹ supported by other studies. By questioning assumptions about the universality of bullying and engaging with the nuanced realities of participants’ experiences, a more honest interpretation of the data emerges, calling for tailored interventions informed by contextualised analyses of organisational cultures and individual motivations.³²^,⁴⁰^,⁵¹^,⁶⁰

Additionally, surgeons’ beliefs about what is required in the future to build on the momentum of behavioural and cultural change were explored. The analysis revealed several key themes. First, there was broad consensus on the importance of expanding the OWR program to broader cohorts of surgeons, surgical trainees, and other health professionals. Additionally, this research supports the call in the literature for greater accountability and consequences for serial bullying aggressors, along with empowerment and support for those experiencing bullying, particularly during complaints processes.¹⁵^,²⁴^,³²^,⁴⁶^,⁶¹ Participants also highlighted the significance of fostering an explicit positive surgical culture³⁴^,⁴⁰^,⁴⁸^,⁶² and utilising surgical leadership²⁴^,⁴⁶^,⁶³^–⁶⁵ to establish and manage behavioural standards. Lastly, respondents in this study identified a need for proactive screening of potential bullies early in their surgical careers and the removal of known bullies from positions of influence for long-term improvement in workplace behaviour. Failing to do so was perceived as symbolically undermining to the RACS’s and employers’ efforts.²⁴

Limitations

Recall bias: The additional interventions deployed alongside anti-bullying training may have made it challenging for participants to differentiate the impact of each intervention when completing the survey.
Impact of COVID-19 pandemic: Although the survey was conducted during the COVID-19 pandemic and no explicit mention of its impact was provided in survey responses, the potential influence of the pandemic on respondent perceptions cannot be entirely discounted.
Perception-based data: This study’s findings are based on the self-reported perceptions of surgeons, which may not reflect actual reductions of workplace bullying behaviours.
Limited representation of trainees or other surgical team members: More senior surgeons were surveyed in comparison to junior surgeons, which may limit generalisability of findings.
Lack of transferability: Insights from this study on the OWR program in RACS may not be directly applicable to other healthcare settings with different training structures and regulatory frameworks.

Conclusion

This study found that the OWR program, which includes a full-day anti-bullying training course, is perceived by surgeons in Australia and Aotearoa New Zealand to be moderately effective in reducing workplace bullying. Nonetheless, the program’s impact is substantially amplified when integrated into a broader, multi-dimensional ecosystem of reform. Our analysis highlights the need for a prolonged, consistent approach that not only embraces comprehensive policy changes and robust accountability for serial aggressors but also enhances complaints management processes and promotes extensive cultural transformation. Through such integrated efforts, healthcare organisations can more effectively leverage anti-bullying training to foster a respectful work culture and decrease bullying incidents over time.

Data availability

The datasets generated or analysed during the current study are available from the corresponding author upon reasonable request.

Conflicts of interest

The authors declare that there are no conflicts of interest in relation to this study.

Declaration of funding

The Professional Doctorate receives funding from the Australian Research Training Scheme. The primary author does not have a personal scholarship.

Acknowledgements

RACS has been a key partner in this research and assisted with the administrative aspects of recruiting surgeons. We thank the surgeons who completed the survey.

Author contributions

Paul Gretton-Watson: conceptualisation, data curation, methodology, project administration, writing – original draft, and writing – review and editing (lead); Jodi Oakman: supervision (lead) and writing – review and editing (supporting); and Sandra G. Leggat: supervision (supporting) and writing – review and editing (supporting).

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Appendix 1.Executive summary of the RACS’s EAG report in 2015.

Following is an excerpt from the EAG Report¹⁶ p. 4 published in 2015.

Executive summary

There was strong participation in all consultations and surveys and the research results are robust and valid. Research results and consultation feedback confirm that discrimination, bullying, and sexual harassment are pervasive and serious problems in the practice of surgery in Australia and New Zealand. The effects are significant and damaging. Discrimination, bullying, and sexual harassment affect not only the individuals who are subjected to these behaviours, but also the healthcare teams who witness or are part of them, and patients whose safety is risked as a result of them. The research shows that there are some surgeons who do not believe these problems exist. There was considerable support for the College in tackling these issues and establishing the EAG. As well, most participants valued the profession and the enormous contribution it makes to the healthcare sector and the community. Among those who believed there are serious issues to address, there was hope that lasting, positive change can be achieved. The EAG accepts the view that there are serious issues to address. It focuses on the problems that have been identified and makes recommendations aimed at lasting change. The EAG recognises the enormous contribution of surgeons to the healthcare sector and the community, the integrity and positive role modelling of many in the profession, and the commitment of the College in establishing and resourcing the EAG, and leaving it to do its work unconstrained. The research found that:

49% of Fellows, Trainees, and International Medical Graduates report being subjected to discrimination, bullying or sexual harassment;
54% of Trainees and 45% of Fellows less than 10 years post-fellowship report being subjected to bullying;
71% of hospitals reported discrimination, bullying, or sexual harassment by a surgeon in their hospital in the last 5 years, with bullying the most frequently reported issue;
39% of Fellows, Trainees, and International Medical Graduates report bullying, 18% report discrimination, 19% report workplace harassment, and 7% sexual harassment (some reporting more than one behaviour);
the problems exist across all surgical specialties in both countries and all regions; and
senior surgeons and surgical consultants are reported as the primary source of these problems.